Breast Cancer-Related Employment Disruption and Financial Hardship in the Sister Study

Catastrophic health expenditures, insurance churn, and non-employment among women with breast cancer

BACKGROUND

Breast cancer treatment and survivorship entails a complex and expensive continuum of subspecialty care. Our objectives were to assess catastrophic health expenditures, insurance churn, and non-employment among women younger than 65 years who reported a diagnosis of breast cancer. We also evaluated changes in these outcomes related to implementation of the Affordable Care Act.

METHODS

The data source for this study was the Medical Expenditure Panel Survey (2005-2019), which is a national annual cross-sectional survey of families, providers, and insurers in the United States. To assess the impact of breast cancer, comparisons were made with a matched cohort of women without cancer. We estimated predicted marginal probabilities to quantify the effects of covariates in models for catastrophic health expenditures, insurance churn, and non-employment.

RESULTS

We identified 1490 respondents younger than 65 years who received care related to breast cancer during the study period, representing a weight-adjusted annual mean of 1 062 129 patients. Approximately 31.8% of women with breast cancer reported health expenditures in excess of 10% of their annual income. In models, the proportion of women with breast cancer who experienced catastrophic health expenditures and non-employment was inversely related to increasing income. During Affordable Care Act implementation, mean number of months of uninsurance decreased and expenditures increased among breast cancer patients.

CONCLUSIONS

Our study underscores the impact of breast cancer on financial security and opportunities for patients and their families. A multilevel understanding of these issues is needed to design effective and equitable strategies to improve quality of life and survivorship.

Short-term and long-term financial toxicity from breast cancer treatment: a qualitative study

PURPOSE

The rising cost of breast cancer treatment has increased patients' financial burden, intensifying an already stressful treatment process. Although researchers increasingly recognize the harmful impact of medical and nonmedical costs associated with cancer treatment, understanding patients' perspectives of financial toxicity is limited. We aimed to explore the topic of financial toxicity through the lived experiences of patients with breast cancer from groups at risk of social and economic marginalization.

METHODS

We conducted semi-structured interviews with 50 women with breast cancer from four specific groups: Black women, Medicaid enrollees, rural residents, and women age ≤ 40. We transcribed, coded, and analyzed the data using deductive and inductive approaches.

RESULTS

Two overarching themes captured patients' experiences of financial toxicity: short-term and long-term impacts. Short-term stressors included direct medical (e.g., co-pays, premiums), nonmedical (e.g., transportation, lodging), and indirect (e.g., job loss, reduced work hours) costs. Early in their treatments, patients' focus on survival took precedence over financial concerns. However, as the treatment course progressed, fear of consequences from compounding costs of care and financial distress negatively impacted patients' lifestyles and outlooks for the future.

CONCLUSION

Programs addressing financial toxicity that look beyond early-phase interventions are needed. Specifically, patients struggling with the accumulation of treatment costs and the resultant stress require ongoing support. Long-term support is especially needed for groups vulnerable to financial instability and social marginalization.

Evaluation of financial toxicity and associated factors in female patients with breast cancer: a systematic review and meta-analysis

PURPOSE

These systematic review and meta-analysis were conducted to discuss the financial toxicity (FT) level among breast cancer (BC) patients and the associated demographic and economic factors.

METHODS

A systematic review and meta-analysis of single means were used by following the Joanna Briggs Institute guidelines and PRISMA guidance. Untransformed means (MRAW) were used to estimate the confidence interval for individual studies, while I2 and tau2 statistics were used to examine heterogeneity among pooled studies. Electronic databases were PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE(R), Science Direct, and Turkish databases were used to find relevant studies published in the last 15 years (between 2008 and 2023).

RESULTS

A total of 50 studies were reviewed in the systematic review, and 11 were included in the overall and subgroup meta-analyses. The majority of reviewed studies were from the USA (38 studies), while there were four studies from China and eight studies from other countries having different types of health systems. The overall estimated FT level based on 11 pooled studies was 23.19, meaning mild level FT in the range of four categories (no FT score > 25, mild FT score 14-25, moderate FT score 1-13, and severe FT score equal to 0), with a 95% CI of 20.66-25.72. The results of subgroup meta-analyses showed that the estimated FT levels were higher among those patients who were single, with lower education levels, stage 3 patients, younger, lower income, unemployed, and living in other countries compared to those who were married, more educated, and stages 1 and 2 patients, more aged, more income, employed, and patients in the USA.

CONCLUSION

The cost-effectiveness of the treatment strategies of BC depends on the continuity of care. However, FT is one of the leading factors causing BC patients to use the required care irregularly, and it has a negative effect on adherence to treatment. So, removing the economic barriers by taking appropriate measures to decrease FT will increase the efficiency of already allocated resources to BC treatments and improve the health outcomes of BC patients.

Association of Employment Disruptions and Financial Hardship Among Individuals Diagnosed with Cancer in the United States: Findings from a Nationally Representative Study

Financial hardship (FH), defined as adverse patient effects due to cancer costs, is experienced by approximately half of individuals diagnosed with cancer. Many individuals diagnosed with cancer also experience disruptions with their employment. This study examines associations of employment disruptions and FH among a nationally representative sample of individuals diagnosed with cancer in the United States. We utilized 2016/2017 Medical Expenditure Panel Survey Experiences with Cancer data from individuals who worked for pay following cancer diagnosis. Employment disruption included taking extended paid time off work; switching to part-time/less demanding jobs; and/or retiring early due to cancer diagnosis/treatment. FH domains included: material (e.g., borrowing money/financial sacrifices); psychologic (e.g., worrying about medical bills/income); and behavioral (delaying/forgoing healthcare services because of cost). Multivariable logistic regression analyses determined associations of employment disruption and FH. Among 732 individuals with a cancer history, 47.4% experienced employment disruptions; 55.9% experienced any FH. Any FH was significantly more common among individuals with versus without employment disruptions across multiple measures and domains (68.7% vs. 44.5%; P value of difference <0.0001). Individuals with employment disruptions were more likely to have any FH [OR, 2.38; 95% confidence interval (CI), 1.62-3.52] and more FHs (OR, 2.76; 95% CI, 1.96-3.89]. This study highlights that employment disruptions are common and significantly associated with multiple domains of FH among individuals with a cancer history. Employer workplace accommodation, physician discussions regarding potential impacts of cancer care on employment, and other policies to minimize employment disruptions among individuals diagnosed with cancer may reduce FH in this vulnerable population.

Significance

Individuals diagnosed with cancer may have employment disruptions; they may also develop FHs. People with cancer who have employment changes are more likely to also have FHs. Physicians and employers can help individuals with cancer through advancing planning, workplace assistance, and improved medical leave and insurance policies.

Characteristics and influencing factors of social isolation in patients with breast cancer: a latent profile analysis

PURPOSE

The goal of this study is to investigate the social isolation (SI) subtypes of patients with breast cancer (BC) and to explore its influencing factors.

METHODS

A sample of 303 BC patients participated in the study from September to December, 2021. Latent profile analysis (LPA) was performed to identify SI clusters based on the three sub-scales of the Chinese version of the Social Anxiety Scale, the Chinese version of the Social Avoidance and Distress Scale, and the Chinese version of the Loneliness Scale.

RESULTS

We found that SI can be divided into three categories: high-level (Class 1), middle-level (Class 2), and low-level (Class 3), accounting for 20.46%, 33.00%, and 46.54%, respectively. Compared to Class 3, Class 1, which had the lower average monthly income per family member (RMB) (< 3000: OR = 5.298, P = .021; 3000 ~ 5000: OR = 5.320, P = .018), was more likely to suffer from SI due to occupation (Laborer: OR = 12.023, P = .009). Surgery (OR = 14.138, P < .001; OR = 2.777, P = .020), chemotherapy (OR = 10.224, P = .001; OR = 3.545, P = .001); poorer family functioning (OR = .671, P < .001; OR = .801, P = .002), and lower levels of self-transcendence (OR = .806, P < .001; OR = .911, P < .001) were important influencing factors for SI in Class 1 and Class 2 compared to Class 3.

CONCLUSION

SI is classifiably heterogeneous among patients with BC. Strategies that identify characteristics of SI and give targeted intervention focusing on family functioning and improving self-transcendence levels contribute to the prevention of SI among patients with BC.

Breast cancer and occupation: Non-parametric and parametric net survival analyses among Swiss women (1990–2014)

Introduction

Occupation can contribute to differences in risk and stage at diagnosis of breast cancer. This study aimed at determining whether occupation, along with skill level and the socio-professional category, affect the breast cancer survival (BCS) up to 10 years after diagnosis.

Materials and methods

We used cancer registry records to identify women diagnosed with primary invasive breast cancer in western Switzerland over the period 1990–2014 and matched them with the Swiss National Cohort. The effect of work-related variables on BCS was assessed using non-parametric and parametric net survival methods.

Results

Study sample included 8,678 women. In the non-parametric analysis, we observed a statistically significant effect of all work-related variables on BCS. Women in elementary occupations, with low skill level, and in paid employment not classified elsewhere, had the lowest BCS, while professionals, those with the highest skill level and belonging to top management and independent profession category had the highest BCS. The parametric analysis confirmed this pattern. Considering elementary occupations as reference, all occupations but Craft and related trades had a hazard ratio (HR) below 1. Among professionals, technicians and associate professionals, and clerks, the protective effect of occupation was statistically significant and remained unchanged after adjustment for age, calendar period, registry, nationality, and histological type. After adjusting for tumor stage, the HRs increased only slightly, though turned non-significant. The same effect was observed in top management and independent professions and supervisors, low level management and skilled laborers, compared to unskilled employees.

Conclusion

These results suggest that work-related factors may affect BCS. Yet, this study was conducted using a limited set of covariates and a relatively small study sample. Therefore, further larger studies are needed for more detailed analyses of at risk occupations and working conditions and assessing the potential interaction between work-related variables and tumor stage.

Intention to work among outpatients with malignant neoplasms, ischemic heart disease, and cerebrovascular disease

Objectives

Employment support for working age people with disease is important. We investigated the intention to work among outpatients with malignant neoplasms, ischemic heart disease, and cerebrovascular disease.

Methods

We used anonymous data from the 2007, 2010, and 2013 Comprehensive Survey of Living Conditions in Japan, a self-administered nationwide questionnaire survey. Data for 154,445 participants (76,059 men and 78,386 women) aged 20-64 years were analyzed using logistic regression models adjusted for covariates.

Results

The number of outpatients with malignant neoplasms, ischemic heart disease, and cerebrovascular disease was 851, 1,037, and 716, respectively. The adjusted odds ratio for not working in people with the intention to work was significantly higher among outpatients with the three diseases than among non-outpatients, for both men and women. The adjusted odds ratio for intention to seek permanent work in unemployed people with the intention to work was lower among outpatients with cerebrovascular disease than among non-outpatients for men (p=0.093), and was significantly higher among outpatients with malignant neoplasms than among non-outpatients for women (p=0.007).

Conclusions

This study identified a high proportion of unemployed people with the intention to work among outpatients with these three diseases, and suggests that there are disease-associated differences in employment type sought.

Trajectories and predictors of social avoidance in female patients with breast cancer

BACKGROUND

Social avoidance plays an important role in influencing quality of life among patients with breast cancer. Social avoidance behaviors change with treatment periods. However, the trajectory patterns and the predictive factors have not been fully studied.

OBJECTIVE

This study examined the growth trajectory of social avoidance and its predictors in patients with breast cancer.

MATERIALS AND METHODS

A total of 176 patients with breast cancer in a university hospital in Shaanxi Province, China, were followed up four times over 6 months following surgery, and data from the final 144 patients were analyzed. The growth mixed model (GMM) was used to identify the trajectory categories, and the predictive factors of the trajectory types were analyzed by logistic regression.

RESULTS

The best-fit growth mixture modeling revealed three class models: persistent high social avoidance group (Class 1), social avoidance increased first and then decreased group (Class 2), and no social avoidance group (Class 3), accounting for 13.89, 31.94, and 54.17% of patients, respectively. Single-factor analysis showed that family income per capita, residence, and temperament type were related to the social avoidance trajectory. Logistic regression analysis showed that only temperament type was an independent predictor of the social avoidance trajectory, and patients with melancholia were more likely to have persistent high social avoidance.

CONCLUSION

Our study proved the heterogeneity of social avoidance behaviors and the influencing effect of temperament type on the development of social avoidance behaviors in Chinese patients with breast cancer. Health professionals should pay more attention to patients who are at higher risk of developing a persistent social avoidance pattern and provide target interventions.

Financial Toxicity and Shared Decision Making in Oncology

Oncologists are often ill-prepared for patient-provider communication about the financial costs and burden of treatment. Several barriers to cost communication exist, including provider discomfort, lack of knowledge or access to accurate information, and background historic concerns that cost discussions may negatively impact the doctor-patient relationship. However, clear and transparent cost communication can yield cost-reducing strategies that ultimately mitigate the high costs of cancer care and risk for financial toxicity.